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i. <br /> MARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> 5155 Silverton Rd NE (to be completed by system installer) <br /> SALEM OR 97305 <br /> 503-588-5147 PERMIT NO. S ( S -VI-ao at , 9 <br /> MARION <br /> COUNTY http://www.co.marion.or.us/PW/BuildingInspection �gf I-,SITE ADDRESS: (� �2 �r` , t I t <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale: 1"= 3 — rs <br /> • Nnrth C, <br /> itYcrft <br /> See <br /> A -c. = gs <br /> c a A 2-c .161c{,. <br /> 1' <br /> h <br /> �i r <br /> \' e to <br /> 0 <br /> too <br /> p1-•4,v— <br /> (show all details and dimensions necessary to locate all components of the system in the future) <br /> SYSTEM MATERIALS AND SPECIFICATIONS: INSTALLERS CERTIFICATION: <br /> I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> System Design Sewage Flow JO W Gallons/Day STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: (TOO total gallons • P1 single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> Manufacturer: (t A 1&c.�$ G t•d tf,$.}.onl [ j double compartment <br /> OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: ('ca-.E.v�e&-s._ ll [ ] flow-through Jfu have tested the septic tank and certify it to be watertight. <br /> Effluent Sewer:� Header Pipe: �. The system was installed by: <br /> Size/Mat'I v 0 3 IA L( Size/Mat'l 41 I I Property Owner(permittee) <br /> IQ,jeicensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) <br /> Rock and under pipe \j [/ prop I I Concrete DEQ License Number: ?QOra <br /> Pipe total depth y - 30 I I Distribution . astic <br /> `� }.�.Pl DEQ Certification Number: 2 t tZ <br /> Drainfield Material(Alternative or pert.pipe) It'' OK_ Sr— . <br /> Total Drainfield Footage soa, Trench Depth Minimum 9 Maximum ra <br /> Curtain Drain Depth Signed: / <br /> Effluent Pump: Pump Model . <br /> Pump cycle � / <br /> times in minutes: on off Gallons per Cycle Company name: OA /k/(�G(1c.Gt1— ( k C___ <br /> ATT Make and Model //�� (please print) <br /> qAttach an additional sheet for components and materials not listed above. Date: - //b' 23 <br /> (For Marion County Use Only) The above septic system has been inspected by Marion County. The information has been determined to be accurate <br /> and the system is: lokApproved [ I Approved wi h corrections:see inspection report [ I Denied I f <br /> Signed: �� Title: l I S ozZ ' Date: k O /Zt1 ZL _ <br /> MC'S-41 rev:3/03:4/12:5/14. 11/17 Cr\Forme\Centic\S-41 As-Rlrilt701 SVercinn7f117 rinr WHJTF•AA.+nn IM,,,,h,• VP!Inw•n,,,.,,,. Aivt' 1„,,.,11a. <br />